Please note that you will require at least 10-15 minutes to fill this form. You will not be able to save your work and come back at a later date to complete where you left off. You will need to start a new application at that time.

* Indicates required fields

1. Select the campus you wish to attend:

*
San Diego Campus
New York Campus
Chicago Campus

2. Applying for program:

San Diego

Doctorate of Acupuncture and Oriental Medicine (DAOM)

Master of Science (Traditional Oriental Medicine)

Bachelor of Health Science (Asian Holistic Health and Massage)

Associate of Science(Massage Therapist/Asian Bodywork Certificate)

Associate of Applied Science (Holistic Health Science)

Massage Therapist/Asian Bodywork Certificate

Public Education

Non-Matriculated Student

New York

Bachelor of Professional Studies/Master of Science in Oriental Medicine

Bachelor of Professional Studies/Master of Science in Acupuncture

Bachelor of Professional Studies (Asian Holistic Health and Massage)

Associate of Occupational Studies (Massage Therapies)

Bachelor's - Holistic Nursing

Certificate in Herbal Medicine for L.Ac. Practitioners

Public Education

Non-Matriculated Student

Chicago

Master of Science Traditional Oriental Medicine, MSTOM

Bachelor of Science in Asian Holistic Health and Massage, BS

Associate of Science (Massage Therapy/Asian Bodywork), AS

Associate of Applied Science in Massage Therapies, AAS

Massage Therapy/Asian Bodywork Certificate

Public Education

Non-Matriculated Student

*Beginning: Year*Semester:
Fall
Winter
Spring

3. Personal Information:

*Legal First Name:

Legal Middle Name:

*Legal Last Name:

*Present Address:

*City:

*State:

(eg. CA)

*Zip:

*Country:

*Home Phone:

eg. 6195746909 (no spaces)

Cell Phone:

*Email Address:

*Confirm Email:

Fax, if available:

Is your permanent address the same as your present address? No
Yes

Permanent Address:

City:

State:

(eg. CA)

Zip:

Country:

Home Phone:

Cell Phone:

*Date of Birth:

(mm/dd/yy)

*Age:

*Country of Birth:

*Sex:

Male
Female

4. If you are a US Citizen, please select "Not applicable"

If you are not a U.S. Citizen, what is your country of citizenship?

Answer:

Are you planning to apply for a student (F-1 or M-1) visa?

*Answer:

Yes
Not applicable

If yes above, answer a-d. If not applicable, go to 5

a) The I-20 should be sent to (check one):

Answer:

Permanent address
Present Address

b) My financial sponsor is (include name and relationship):

Answer:

c) Will you be bringing your spouse and/or children?

Answer:

Yes
No

If yes, please write the first and last name, date of birth, country of birth and relationship of each dependant in the box below:

Answer:

d) Were you enrolled in another U.S. College/School within 5 months of enrollment at Pacific College?

Answer:

Yes
No

5.

If you are not going to apply for a US Visa, please check the appropriate box below:

TOPIC: The nature and demands of the Oriental medical/holistic health profession require personal attributes and motivation, which complement intellectual abilities. Please address the following topics:

Describe what you think makes you a good candidate to become an Oriental medicine practitioner.

Discuss experiences you have had and how these experiences and your values could make a contribution to your own and your patients’ healthcare.

As this education is also a process of self-exploration, identify some ways you hope to develop personally on your journey to becoming a healer and how you envision that process.

Are you able to completely finance your own education (tuition, fees, living expenses, transportation, etc.)?

*Answer:

Yes
No

If no, please estimate the amount of supplementary funds you will need from grants, loans, scholarships or other personal sources during your enrollment at Pacific College:

Answer $:

What resources(s) will you use to fund your education?

Answer:

Financial Aid
VA Benefits
Cash
Other

10. Employment and volunteer service:

Please list all paid employment (full and part-time) and/or voluntary service for at least the last three years beginning with your most recent position:

From Month/Year

To Month/Year

Total months

Hours per wk

Position

Organization

City & State

11. References:

Two Letters of reference from persons familiar with the applicants academic abilities, maturity, and integrity (Two references required only for Acupuncture program applicants).

First Referent (not required for PubEd and Non-matriculated programs):
First Name: Last Name: Email:
Write a short note to your referent (optional):

Second Referent (not required for AOS, AAS, PubEd and Non-matriculated programs):
First Name: Last Name: Email:
Write a short note to your referent (optional):

Under the Family Education Rights and Privacy Act of 1974, you have the right to review any information collected as part of your admissions application, including letters of reference. Most individuals you may ask for character references would prefer that their responses be kept confidential. Furthermore, the Admissions Committee at Pacific College gives greater weight to confidential responses where the prospective student waives the right to review such letters. Please indicate below if you would like to waive the right.

I waive my right to review any information provided by the referent for evaluation in support of my application to Pacific College.

12. Racial/Ethnic status (optional):Check one box only:

Nonresident alien
Hispanic/Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Two or more races
Race and ethnicity unknown

13. Other information:

Have you been convicted of a felony?

Yes No

T-shirt selection:

other names used; alias’s, maiden names, etc:

* How did you
hear about us:

If other, please specify:

I own a laptop computer:

Yes
No

I own a desktop computer:

Yes
No

14. Agreement Confirmation:

I hereby make Application for Admission to Pacific College of Oriental Medicine, and certify that all information given on this application is true.